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研究生:吳紀萱
研究生(外文):Chi-HsuanWu
論文名稱:以腹部超音波影像提供視覺回饋之骨盆穩定運動對患有妊娠相關骨盆帶疼痛的產後婦女效應
論文名稱(外文):Effects of Pelvic Stabilization Exercise with Transabdominal Ultrasonography-guided Biofeedback in Postpartum Women with Pregnancy-related Pelvic Girdle Pain
指導教授:蔡一如蔡一如引用關係
指導教授(外文):Yi-Ju Tsai
學位類別:碩士
校院名稱:國立成功大學
系所名稱:物理治療學系
學門:醫藥衛生學門
學類:復健醫學學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:中文
論文頁數:104
中文關鍵詞:妊娠相關骨盆帶疼痛產後婦女骨盆穩定運動骨盆底肌視覺回饋超音波
外文關鍵詞:Pregnancy-related pelvic girdle painPostpartum womenPelvic stabilization exercisePelvic floor musclesVisual biofeedbackUltrasonography
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背景與目的:患有妊娠相關骨盆帶疼痛的產後婦女比例極高,且妊娠相關骨盆帶疼痛大大影響產後婦女的日常活動、心理狀態、生活品質、與家庭關係。但至今相關介入性研究仍很缺乏且結果仍不一致。懷孕與生產皆會使腹肌與骨盆底肌功能受損。因此,妊娠相關骨盆帶疼痛可能與維持脊椎骨盆帶穩定的機制改變有關,肌肉的活化不足或過多,使得動作控制受損,導致疼痛與失能情形產生。骨盆底肌是提供骨盆穩定重要來源之一,所以骨盆帶穩定性運動強調骨盆底肌收縮活化或許可以減輕骨盆帶疼痛問題。然而產後婦女發現有嚴重骨盆底肌失能問題,常以不正確方式收縮骨盆底肌。先前研究指出非侵入式之經腹部超音波影像提供骨盆底肌控制的視覺回饋,可以幫助肌肉收縮學習,或許有助於改善疼痛失能。因此本研究目的為探討以非侵入式之經腹部超音波影像提供骨盆底肌控制的視覺回饋,應用於八週骨盆穩定運動介入中,對於產後患有妊娠相關骨盆帶疼痛的婦女之肌肉功能、身體功能、疼痛失能狀況、與生活品質的改善情形。方法:本研究採單盲隨機臨床試驗之平行設計,以產後3個月後仍存有妊娠相關骨盆帶疼痛婦女為研究對象。共28位婦女完成研究,包括運動訓練加超音波視覺回饋組14人,與運動訓練組14人。所有婦女皆接受8週的骨盆穩定運動介入,前四週為骨盆底肌活化訓練,後四週加入身體核心肌群與周圍外在大肌群之功能整合性運動。兩組之所有運動處方內容皆一致,唯加入超音波視覺回饋組的婦女在前四週骨盆底肌活化訓練中提供4回合經腹部超音波影像之視覺回饋。所有評估項目在介入前與介入後執行,包含疼痛程度(疼痛數字等級量表)、失能狀況(骨盆帶疼痛功能問卷與歐氏下背痛失能量表)、生活品質(SF-36生活品質量表)、功能性表現(自主性直膝抬腿疲勞測試、三公尺計時起走測試、六公尺快速行走測試),以及用超音波影像系統量測休息時和肢體動作時(自主直膝抬腿)腹肌與骨盆肌肉的肌肉厚度與收縮情形。並且在8週運動介入過程中,評估每週骨盆底肌正確收縮狀況。結果:8週運動介入後,運動訓練加超音波視覺回饋組在主觀疼痛失能與生活品質量表方面和所有功能性測試上有顯著性的改善(p〈0.05),且達到臨床顯著意義;而運動訓練組在主觀疼痛失能與生活品質量表方面有顯著性的改善(p〈0.05),但功能性測試方面僅在健側直膝抬腿測試有顯著改善(p〈0.05)。然而介入後的兩組結果比較,在統計學上皆未有顯著性的差異。關於超音波影像結果,兩組組內比較上,在休息時的腹內斜肌之肌肉厚度或腹直肌分離距離有統計上顯著變化,但是此差異極小,並不具臨床意義。於運動介入過程中每週評估骨盆底肌正確收縮能力結果發現,整體而言加入超音波視覺回饋有較佳之骨盆底肌正確收縮表現。運動訓練加超音波視覺回饋組在第二週骨盆底肌正確收縮率相較於第一週評估有顯著性的提升(p = 0.033)且之後大致都能維持,且第八週之骨盆底肌正確收縮率顯著高於第一週評估。在第六週評估時,運動訓練加超音波視覺回饋組中,可以持續做出正確骨盆底肌收縮達到動作學習理論之連結階段的人數較單純運動訓練組多人(p = 0.05)。討論與結論:產後患有妊娠相關骨盆帶疼痛婦女,在8週的骨盆穩定運動介入後,不論是運動訓練加超音波視覺回饋組還是運動訓練組,在身體功能、疼痛程度、失能狀況及生活品質上,皆獲得了改善。雖然8週的骨盆穩定運動介入仍未觀察到腹部肌肉厚度或骨盆底肌收縮的改變。加入超音波視覺回饋較能增進骨盆底肌正確收縮的學習,然而這個學習效益目前無法延伸連結至疼痛失能的減緩。運動訓練加入超音波視覺在本研究中,相較於單純運動訓練,並沒有更顯著的改善疼痛與功能的效果。由於本研究樣本數較小、婦女骨盆帶疼痛失能嚴重度較低、或已有較佳之骨盆底肌收縮能力、婦女職業狀況差異、提供視覺回饋時間較短、或是因為新冠肺炎影響有較高退出率等等因素限制,未來研究仍可針對此議題深入探討。
This is a exercise intervention study for postpartum women with pregnancy-related pelvic girdle pain (PPGP). The main purposes for this study are to investigate the effects of transabdominal sonography-guided biofeedback pelvic stabilization training on decreasing pain and disability, improving muscle functions, and enhancing physical performance, as well as improving quality of life in postpartum women with PPGP. Twenty-eight women suffering from postpartum PPGP were randomly assigned to the transabdominal sonography-guided biofeedback group (n=14) or exercise group (n=14). All the participants received the same 8-week pelvic stabilization exercise intervention emphasizing on the pelvic floor muscle training. Except the women in the transabdominal sonography-guided biofeedback group received additional 4 times biofeedback training for the pelvic floor muscles. The outcome assessment included pain intensity, disability level, quality of life, functional performance, and the sonographic measures of muscle thickness and control of abdominal and pelvic floor muscles. In addition, the correctness of pelvic floor muscle contraction was assessed each week using the transabdominal sonography. After 8-week intervention, the pain, disability, quality of life, and functional performance were significantly improved in both groups. But no statistical difference was found between the two groups. In overall, the transabdominal sonography-guided biofeedback group tended to have higher rate of correct pelvic floor muscle contraction. In conclusion, 8-week pelvic stabilization exercise intervention in the current study was able to improve pain, disability, quality of life, and functional performance for the postpartum women with PPGP. The transabdominal sonography-guided biofeedback might facilitate the correct learning of the pelvic floor muscles contraction.
致謝 ....................................................I
中文摘要 .............................................. III
English abstract ....................................... V
目錄 ...................................................XI
圖目錄 ................................................XIV
表目錄 ................................................ XV
第一章 緒論 ............................................. 1
第一節 研究背景 ......................................... 1
第二節 研究假說與目的 ................................... 3
第二章 文獻探討 ......................................... 4
第一節 妊娠相關骨盆帶疼痛之流行病學 ...................... 4
第二節 妊娠相關骨盆帶疼痛之影響 .......................... 5
一、 骨盆帶肌肉功能 ..................................... 5
二、 動作知覺與協調 ..................................... 6
三、 日常活動 .......................................... 7
四、 情緒 .............................................. 8
五、 家庭功能 .......................................... 8
第三節 妊娠對骨盆帶穩定之影響 ............................ 8
一、 骨盆穩定的機制 ..................................... 8
二、 骨盆底肌之解剖構造與功能 ........................... 13
三、 妊娠對骨盆帶穩定的影響 ............................. 17
第四節 目前現有妊娠相關骨盆帶疼痛之介入研究 .............. 20
一、 懷孕時期之介入 .................................... 20
二、 分娩後之介入 ...................................... 22
第五節 超音波視覺回饋對於骨盆底肌之應用 .................. 26
一、 婦女骨盆底肌收縮失能 .............................. 26
二、 超音波量測骨盆底肌 ................................ 27
三、 經腹部超音波結合骨盆底肌訓練 ....................... 27
第六節 總結 ........................................... 28
第三章 研究方法 ....................................... 30
第一節 研究架構 ....................................... 30
第二節 研究對象 ....................................... 31
一、 選取與排案條件 .................................... 31
二、 樣本數計算 ....................................... 33
三、 隨機分配方式 ...................................... 33
第三節 研究工具 ....................................... 33
一、 疼痛數字等級量表(Numeric rating scale, NRS) ....... 33
二、 骨盆帶疼痛問卷量表(Pelvic girdle questionnaires, PGQ) ... 34
三、 歐氏下背痛失能量表(Oswestry disability index, ODI)... 34
四、 生活品質量表(Short Form-36, SF-36) ................ 34
五、 腹部超音波量系統 .................................. 35
六、 壓力生物回饋儀表 .................................. 37
第四節 評估流程 ....................................... 37
一、 基本資料與妊娠相關骨盆帶疼痛資料收集 ................ 37
二、 功能性測試 ....................................... 37
三、 超音波肌肉量測 .................................... 40
第五節 介入計畫 ....................................... 42
一、 骨盆底肌訓練(前四週) .............................. 43
二、 功能整合性運動(後四週) ............................ 44
第六節 資料處理與分析 .................................. 44
一、 腹部肌肉厚度量測 .................................. 44
二、 上下腹直肌分離量測 ................................ 45
三、 骨盆底肌收縮能力量測: 膀胱底位移量與位移方向 ........ 45
四、 骨盆底肌正確收縮率 ................................ 46
五、 運動依從性 ....................................... 46
第七節 統計分析 ....................................... 47
一、 描述性統計分析 .................................... 47
二、 推論性統計分析 .................................... 47
第四章 研究結果 ....................................... 48
第一節 研究對象基本資料 ................................ 48
第二節 運動訓練加超音波視覺回饋組之介入成效 .............. 50
第三節 運動訓練組之介入成效 ............................. 52
第四節 運動訓練加超音波視覺回饋組與單純運動訓練組介入成效比較 ... 55
一、 兩組間介入前之基準比較 ............................. 55
二、 兩組間介入後之成效比較 ............................. 58
第五節 運動介入期間之骨盆底肌正確收縮率 .................. 61
第五章 討論 ........................................... 63
第一節 疼痛失能與生活品質改善效益 ....................... 63
第二節 日常功能表現改善效益 ............................. 65
第三節 腹肌與骨盆肌肉改善效益 ........................... 66
第四節 視覺回饋效益 .................................... 67
第五節 研究限制 ....................................... 70
第六章 結論 ........................................... 72
參考文獻(reference) ................................... 73
附錄一 妊娠相關骨盆帶疼痛衛生教育手冊 ................... 87
附錄二 運動訓練之單張 .................................. 89
附錄三 骨盆帶運動訓練之覽表 ............................. 97
附錄四 Google運動追蹤表單 ............................. 104
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